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Improving Patient Outcomes: The Value of an Integrated Approach


Only 20% of a person’s health can be attributed to healthcare. What happens outside the hospital and clinic doors is far more important in determining how healthy a person or population will be.

Only 20% of a person’s health can be attributed to healthcare.

This statistic can be rather surprising when it feels like our nation is focused on improving quality of care.


In reality, what happens outside the hospital and clinic doors is far more important in determining how healthy a person or population will be. The social determinants of health (SDoH)—the social, financial, physical, and psychological aspects of an individual’s life—account for more than half of a person’s total health (some professionals say it’s as much as 80%).

The availability of resources to meet daily needs such as safe housing, healthful food, transportation, living wages, and job opportunities all affect a person’s ability to access care and live a healthy life. These barriers, the SDoH, play a key role in health outcomes.


Value-based care has changed the game for providers and payers. Consumers are exerting increasing pressure for higher value providers and services—value that is now defined by patient outcomes. They are no longer willing to pay for the service unless the service is the right service at the right time in the right setting and the overall outcomes are reflective. Two keys to improving outcomes and achieving better patient health are breaking down silos and viewing the patient holistically.

The Power of Connectivity

If providers are to achieve better outcomes at lower costs, SDoH must become a part of their patient care protocol. But, solving SDoH can’t be done in isolation. Bundled payment models demand accountability for care across the patient care continuum. That means providers must be able to collaborate and communicate with a patient’s entire healthcare team.

The challenge in achieving connectivity is not a new revelation to providers. In fact, a recent survey found nearly unanimous agreement (95%), among healthcare executives that creating effective post-acute care networks is their single most pressing need.

Helping a patient get back to health and stay healthy doesn’t stop at the hospital exit door. A patient’s discharge date is not medical terminology for the end of care. In fact, when done well, it’s the next phase in care with added community resources. This requires that providers break down silos that inhibit fluid communication. It also requires changing how we think about healthcare delivery.


One particular cardiology group in the Southeast experienced this first-hand. Concerned about their rates of readmissions, the team charted workflows across care teams. They realized patients were being treated with a patchwork of services and follow up from multiple clinicians, with very little communication among any of them. Changing from a traditional fee-for-service model to a value-based model with coordinated care workflows broke down those silos and opened the lines of communication. The result? 86% of physicians began receiving prompt notification of their patients’ hospital stays. Over 4 years, the group’s 30-day readmission rates declined by more than half.

They successfully replaced the notion of “discharge” with the concept of “transition.”


Treating the Person, Not the Patient

“Treating the person rather than the patient” is not the latest medical jargon. The concept of understanding who the person is and what their life involves is proving to deliver big returns when it comes to improving outcomes. Writing a patient’s prescription is one small step in the care plan. Understanding whether or not the patient can pay for it, pick it up at the pharmacy, and know how to use it requires knowing the person and not simply the patient. Effective post-acute care provides patients with a way to stay connected and alerts the care team if their patient is struggling with their recovery plan.

Research shows that post-discharge follow-up care matters. A Tacoma, Washington, hospital studied 30-day readmission rates on 1,576 discharge transition calls placed over four months. It found that patients who received a post-discharge follow-up call and attended a post-discharge follow-up appointment, had fewer readmissions than those who received only a call, and experienced fewer readmissions than those who did not attend a follow-up appointment.


Improving population health and patient outcomes requires a commitment to collaboration, communication, and accountability across the entire provider network. Breaking down traditional delivery silos to open up connectivity will be the new normal in value-based care. In addition, providers must be aware of the life challenges facing their patients outside the hospital or clinic setting, and factor those individual barriers into their care plans.

Can our nation deliver leading-edge healthcare? It’s possible, but not without knowing patients as people. A coordinated effort to acknowledge and solve the SDoH is the key to population health.


1. Bradley, EH, Taylor LA, Coyle CE, Ndumele C, et al.

Yale Global Health Leadership Institute, prepared for Blue Cross Blue Shield of Massachusetts Foundation, June 2015.

Leveraging the Social Determinant of Health: What Works?

2. Q&A: Building the business case for achieving health equity. Modern Healthcare. April 23, 2016.

. Accessed May 13, 2017.


3. Premier. Economic outlook spring 2016 c-suite survey.

. Accessed May 13, 2017.


4. Spreeman, S. Changing mindsets to transform care. May 2016.

. Accessed May 13, 2017.


5. TAV Health. The Next Generation of Healthcare.

. Accessed May 13, 2017.


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